Comparative Effectiveness and Safety of Methods of Insulin Delivery and Glucose Monitoring for Diabetes Mellitus: A Systematic Review and Meta-analysis.
Yeh, Hsin-Chieh PhD; Brown, Todd T. MD, PhD; Maruthur, Nisa MD, MHS; Ranasinghe, Padmini MD, MPH; Berger, Zackary MD, PhD; Suh, Yong D. MBA, MSc; Wilson, Lisa M. ScM; Haberl, Elisabeth B. BA; Brick, Jessica MD; Bass, Eric B. MD, MPH; Golden, Sherita Hill MD, MHS
[Review]
Annals of Internal Medicine.
157(5):336-347, September 4, 2012.
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Background: Patients with diabetes mellitus need information about the effectiveness of innovations in insulin delivery and glucose monitoring.
Purpose: To review how intensive insulin therapy (multiple daily injections [MDI] vs. rapid-acting analogue-based continuous subcutaneous insulin infusion [CSII]) or method of monitoring (self-monitoring of blood glucose [SMBG] vs. real-time continuous glucose monitoring [rt-CGM]) affects outcomes in types 1 and 2 diabetes mellitus.
Data Sources: MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials through February 2012 without language restrictions.
Study Selection: 33 randomized, controlled trials in children or adults that compared CSII with MDI (n = 19), rt-CGM with SMBG (n = 10), or sensor-augmented insulin pump use with MDI and SMBG (n = 4).
Data Extraction: 2 reviewers independently evaluated studies for eligibility and quality and serially abstracted data.
Data Synthesis: In randomized, controlled trials, MDI and CSII showed similar effects on hemoglobin A1c (HbA1c) levels and severe hypoglycemia in children or adults with type 1 diabetes mellitus and adults with type 2 diabetes mellitus. In adults with type 1 diabetes mellitus, HbA1c levels decreased more with CSII than with MDI, but 1 study heavily influenced these results. Compared with SMBG, rt-CGM achieved a lower HbA1c level (between-group difference of change, -0.26% [95% CI, -0.33% to -0.19%]) without any difference in severe hypoglycemia. Sensor-augmented insulin pump use decreased HbA1c levels more than MDI and SMBG did in persons with type 1 diabetes mellitus (between-group difference of change, -0.68% [CI, -0.81% to -0.54%]). Little evidence was available on other outcomes.
Limitation: Many studies were small, of short duration, and limited to white persons with type 1 diabetes mellitus.
Conclusion: Continuous subcutaneous insulin infusion and MDI have similar effects on glycemic control and hypoglycemia, except CSII has a favorable effect on glycemic control in adults with type 1 diabetes mellitus. For glycemic control, rt-CGM is superior to SMBG and sensor-augmented insulin pumps are superior to MDI and SMBG without increasing the risk for hypoglycemia.
Primary Funding Source: Agency for Healthcare Research and Quality.
(C) 2012 American College of Physicians